He starts his piece in a pique of moral indignation:
With the help of social media and a
journalist who has turned this matter into a cause célèbre with an unfortunate
mixture of half-truths and innuendo, the critics have managed to control the
debate, and people who believe in the values of the Board have been cowed into
silence. It feels vaguely McCarthyish, and there comes a time when silence is
immoral. This feels like such a time.
Joseph McCarthy was of course the U.S. Senator interrogating
possible communists. However, an
investigative reporter, an electrophysiologist blogger, et al. do not sit in
the seat of power. No, it is the ABIM
that holds great power over the lives and careers of 200,000 physicians in this
country. Indeed, if one must use a 20th
century Republican politician’s name as an adjective appropriately in this case
to describe a person who holds a position of great responsibility and power and
believes himself to be persecuted against all evidence, the correct word
is: Nixonian,
and it applies not to his detractors but to the good doctor himself.
Now, there are many aspects of this ABIM controversy. They include, but are not limited to 1) the
issue of certification, re-certification, MOC, etc. 2) the existence of, reason
for, politics of, and funding of the ABIM Foundation, and 3) the financial
details.
In the interest of space and time, and since it is covered
so exhaustively elsewhere, I will leave aside #1 and #2 for now.
Regarding number 3: After
reading Dr. Wachter’s post I have re-watched Dr. Cutler’s debate with Dr. Baron
from December of 2014 and re-read Dr. Westby Fisher’s posts and Kurt Eichenwald’s
Newsweek stories. What does Dr. Wachter have
to say about the allegations of egregious waste, lavish spending, exorbitant
salaries, and derelict stewardship of trust and resources? Does he dispute the facts? If not, does he offer an explanation that addresses the specifics?
Let’s looks at his piece.
Against the charge that “The Board is All About the Money” he
writes:
As Board members, we constantly
struggled with balancing our fiduciary responsibility to the organization
(including to pay the salaries and the costs of doing the Board’s current work
and innovating) with the burden to the diplomates. ABIM’s MOC process currently
costs physicians about $200-$400 per year (the low end for the internal
medicine certificate only; the higher range is for those maintaining multiple
certificates, like IM/cardiology/interventional cardiology). These costs are
consistent with the fees of other ABMS boards. The argument that this
represents an impossible expense to the vast majority of practicing physicians
is hogwash.
That’s it. They “struggled,”
and the cost is not that much per person anyway, so “shut up” (leave aside for
the moment those that dispute the true cost). [Edit 7/7/15 I will add that it should go without saying that when the Board authorizes wasteful spending it does neither its fiduciary duty to the organization nor its duty to the Diplomates]
His section regarding salaries and the Condo is equally
pithy. He only addresses the CEO’s
salary, for example. Let’s ignore that
for now and assume the CEO deserves every penny. If I round up to one million
for his salary/benefits, we are still left with salaries/benefits for the ABIM
and its Foundation of $29,000,000/year!
This is to run what should essentially be a testing and record-keeping
company, if a large and sophisticated one at that. And again, this is not the budget, just the
payroll. What about the assistant to the
President who Dr. Cutler pointed out made $689,000 in 2011? Do we finally learn her job description or
why she was worth this from Dr. Wachter?
He was on the Board of Directors at the time and presumably voted on the budget. No, it’s not mentioned. How about the two researchers on the benefits
of MOC who made $450,000/year? Are the
salaries mentioned? Is the embarrassing conflict
of interest mentioned? No, nothing. Even the “Senior Vice President of
Communications” reportedly was compensated $293,000 in 2013. The point is it takes a lot of employees
earning large salaries to reach a sum of $29,000,000/year. I
should point out that these are not my facts.
I am simply repeating what I have seen and read reported. No one from the ABIM has substantively
disputed the numbers, nor defended them.
Despite the length of his post, Dr. Wachter also simply ignores them.
Regarding the Condo he essentially admits that it looks bad,
but was really “designed to be revenue neutral” compared to hotel room costs
for consultants. This is thin gruel, if
not outright laughable. First, the only
reason to buy rather than rent is to save money, not break even; and if looking to
save money Dr. Cutler points out less expensive units practically across the
street. He relates having been told that
the Condo the ABIM did purchase was the most expensive real estate in
Philadelphia per square foot! One comes
to the inevitable conclusion that thrift was not exactly a concern at the ABIM
in those days. With the caveat that any
analysis of the finances of the condo vs. hotel rooms obviously leaves aside
the fact that the condo would not suffice if more than three rooms were needed
at a time, let’s take a quick look at the numbers. Traditionally, financial theory in retirement
has suggested that 4%/year may be spent from a well-invested nest egg without
affecting the long-term real principal.
Some argue that this is too high given today’s interest rates and equity
valuations. So, let’s be very
conservative and take 2.3 million invested in index funds and treasuries, and
spend 2.5%/year on hotel rooms. This
comes to $57,500/year. The condo’s
expenses (not taking into account depreciation) were roughly $42,000/year (per
Dr. Wes’ post). So we have at least $100,000/year
in hotel costs that the condo represents if “revenue neutral.” I will let this speak for itself.
As we see, then, Dr. Wachter does not seriously address
any of the allegations of financial waste that have come to light in the last
seven to eight months. On salaries, Four
Seasons meetings, etc. he simply ignores most of the points made by Dr. Cutler
in December, let alone the mountain of additional information that has surfaced
since. In the end, one can only assume
that he neither disputes the facts of the allegations nor defends the ABIM’s
actions (assuming the facts correct) for a simple reason: There is no credible defense.
In his penultimate paragraph he states:
I further believe that this process
must be crafted by members of the profession itself – and if we abrogate that
responsibility, others will fill the void.
Well, to that a great chorus of readers cries out: “If the unelected, unaccountable, unrepresentative,
monopolistic, and profligate ABIM is self-government, then give me George III.”
He ends with a martial metaphor:
“Throw the bums out!” can feel like
progress. But, as the Arab Spring protesters have learned, sometimes it’s
relatively easy to tear down institutions. Rebuilding them is much harder.
This is hyperbole, or course, but I will indulge it. It is true that more often than not bloody
political revolutions and coups do not turn out well. There is a document, 239 years old tomorrow,
that addresses this fact:
Prudence, indeed, will dictate that
Governments long established should not be changed for light and transient
causes; and accordingly all experience hath shewn, that mankind are more disposed
to suffer, while evils are sufferable, than to right themselves by abolishing
the forms to which they are accustomed. But when a long train of abuses and
usurpations, pursuing invariably the same Object evinces a design to reduce
them under absolute Despotism, it is their right, it is their duty, to throw
off such Government, and to provide new Guards for their future security.
Busy internists are not your typical torch and pitchfork
crowd. Prudence is their virtue.
I do not know how this controversy will ultimately end,
but I do know that Dr. Wachter’s post is not an apology, not an adequate
defense, and not a way forward.
